Published 08/2025
As change requires group buy-in and can affect the workflows of multiple stakeholders, patient safety and quality improvement (PSQI) cannot be done effectively without a team. This team, as a composite, should understand the care concerns, predict the likely impacts of changes on the workflows of various care team members, be familiar with change management, and have the authority and resources to implement change. The team’s constitution will vary depending on the nature of the quality project. For example, a department’s PSQI standing team may expand to include ad hoc members for their specific expertise. In other cases, fully ad hoc teams can be commissioned to maximize the ownership of specific quality projects.
The essential components of the quality and safety team include:
- An invested team leader responsible for directing the team’s efforts, monitoring progress, and holding team members accountable to deadlines. These leaders should possess the necessary administrative authority to give the efforts legitimacy and help overcome barriers. These team members secure the necessary resources, including adequately supported time for each team member. The leader should adjust the pace of change to match the local culture’s change tolerance and demonstrate resilience in the face of resistance to change.
- Representatives from all the care team roles whose workflows could potentially be impacted. This often includes physicians from multiple specialties and subspecialties, nurses, pharmacists, information technology personnel, unit and clinic front desk personnel, medical assistants and support staff.
- Team members with specific expertise in the science of change management. These experts are often employed by the organization. They may be human factors engineers or have started their careers as nurses or healthcare professionals and obtained advanced training. These team members can recommend which PSQI tools to use, help set goals and suggest how to test the change measures. They also often serve as the project managers.
- The voice of the patient, which can be captured in multiple ways. For example, it may be captured by patients’ in-the-moment comments, by satisfaction surveys generated as part of the data collection plan or by members of a formal patient advisory council. When advisory council members are included, the team leader should provide them with clear guidance and support their role within the team.
Example:
Your Labor and Delivery PSQI team has identified an increasing rate of surgical site infections (SSI) following Cesarean sections and decides to try to address this issue. A few of the patient’s primary obstetricians agree to interview their patients who experienced this adverse outcome. These patients’ responses appear to identify gaps in how they were instructed to care for their wounds.
Next, the team leader invites representatives from the various care team roles involved in cesarean wound care and those potentially involved in a solution. The team leader facilitates a meeting during which the clinicians, nurses, and representatives from the hospital’s infection prevention team review the patient feedback and literature to determine best practices. The team initiates a Plan-Do-Study-Act cycle to implement the new care pathway and team members are assigned roles and due dates. These roles include updating and vetting the current educational materials, educating the nurses and clinicians on the new materials and expectations for postoperative wound care, and determining a data collection plan to enable efficient monthly tracking of outcomes. The team sets a goal of a 25% reduction in post-Cesarean SSI (to match average performance in a state-wide database) within six months of implementation of the new cesarean wound care pathway.
The team lead engages the birth center administrative leader, who agrees to pay for the new materials. Of note, this leader already compensates each member for a protected half-day weekly to support their continuous PSQI efforts. The clinical nurse specialist from the hospital PSQI team, a standing member of the birth center PSQI committee, serves as the project manager and provides monthly process and outcome measure data in a visual format for use by the PSQI team and in a different format for the clinician and nurse stakeholders. The team lead oversees completion of the interventions via brief weekly connections with those working on each component, efficiently addresses any barriers, sets the agenda of the team’s monthly meetings and continually assesses for the need to change direction.
Within six months, the team completed two PDSA cycles and reached the targeted performance. Work shifts to sustaining these gains.
Further Reading:
- Silver SA, Harel Z, McQuillan R, Weizman AV, Thomas A, Chertow GM, Nesrallah G, Bell CM, Chan CT. How to Begin a Quality Improvement Project. Clin J Am Soc Nephrol. 2016 May 6;11(5):893-900. doi: 10.2215/CJN.11491015. Epub 2016 Mar 25. PMID: 27016497; PMCID: PMC4858490.
Institute for Healthcare Improvement. Model for improvement: forming the team. https://www.ihi.org/how-improve-model-improvement-forming-team. Accessed 6.30.25.